This Angel is pissed off. I'm Nurse Anne and I work on large general medical ward in the NHS. These are the wards with the most issues surrounding nursing care. The problems are mostly down to intentional understaffing by hospital chiefs that result in a lack of real nurses on the wards.
"The martyr sacrifices themselves entirely in vain. Or rather not in vain, for they merely make the selfish more selfish, the lazy more lazy and the narrow more narrow"-Florence Nightengale

Saturday, 14 February 2009

Nurses should not take report on all patients on the ward...PART ONE

I got a massive shock to the system when I stupidly returned to the UK following my training and working for a short time in the USA.

Over there I was working on a 36 bed general medical surgical unit. It was considered violently unsafe for a nurse to take any more than 6 patients...12 in an absolute staffing emergency. You could increase the ratios at night due to less interruptions.

We had "pods". Each 6 bed pod had its own nursing station, it's own phone and it's own nurse, it's own supply cupboard and it's own hand washing station. This staff nurse only had handover on those 6 patients. All the info she needed for those 6 patients was right there, not mixed up with the other 30 patients. The idea was that it is extremely dangerous to have handover and irresponsibility for more than your pod on busy day shifts. on nights there was one nurse to 12 so she had 2 pods.

Every single day we had a charge nurse (sister) who was in charge of the whole ward. She was there 5 days a week and knew about all 36 patients on the ward. That was good. She was our leader. It is stupid to expect a staff nurse to come in after days off and take report on 36 patients anyway. It takes forever to get handover on that many patients and it is way too much information to keep track of for any amount of time.

Things change so violently and quickly during the day that if you were trying to care for a group of patients and keep track of all the issues for the whole ward you would fail. This was understood by our managers and anyone else with a fucking braincell. That is why each staff nurse stayed in her own pod, only had handover on those patients. The charge nurse was the only one who had report on all 36 patients from the night charge nurse. She did not have a specific patient assignment. She went from pod to pod checking that the nurse and the patients there were doing okay.

Picture the shock to the system I had when I came to the UK to find that on a 35 bed ward there were only 2 staff nurses, no charge nurse and that we were supposed to listen to report on 35 patients we never saw before. How fucking stupid. On a 35 bed ward there would be 2 or 4 nurses listening to report on all the patients. Report at the beginning of the shift took hours. Now we don't even have four nurses, just two. All the notes for all 35 people are jumbled together at the nurses station and there is only one nurses station and one phone. It's fucktarded.

Let's back up a minute. Decades ago an NHS hospital ward had 35 beds and it worked out that you always had one nurse on duty to know about all of the patients. Matron or charge nurse was there every day without a specific patient assignment. First of all, the patients were no where near as complex as they are today on a general ward. General wards today are full of chronic people with complex problems who would not have lived very long back then.

Decades ago patients stayed in the hospital for a lot longer allowing the staff to get to know them. Things didn't move as fast or happen as fast. There were not as many targets, paperwork and changes throughout the day as there are now. I may do 11discharges in one day now. Things were at a slower pace back then. There were more nurses and everyday there was a charge nurse/sister/matron on the ward in charge. She was there every day and knew that ward like the back of her hand. She had staff nurses to care for the patients while she supervised and kept up with the information.

We don't have any of this going for us now. And it's not our fault.

They certainly won't pay for a charge nurse to be there everyday on top of two staff nurses. Most you get now is a charge nurse and a staff nurse or two staff nurses. Each will take a side of patients. If the charge nurse is the primary nurse for her 12-14 people than it becomes impossible for her to follow what is going on at the other side. We did try and have both nurses listen to both sides and get handover for the whole ward. We failed miserably. There was so much information to know for all those people that report was taking nearly 2 hours. There were so many changes during the day that we couldn't find time to catch each other up. Every time we tried we failed due to interruptions.

The other problem we have is this: Nurses are often working 14 hour shifts 3 days a week rather than being there 5 days a week. Saves the hospital some cash. To come in after 2 or 3 days off and listen to handover on 25 or 35 patients you don't know and then try and keep track of all the information is crazy. It's like begging for errors and mistakes. As a matter of fact we know for a fact that it will cause vital info to get missed out lead to mistakes. American nurses would be shocked at the idea of having all ward nurses know about all the patients on a 25-35+ bed ward. Actually anyone with a fucking brain would be shocked that people think that this could work nowadays.

I need to go now and will finish part 2 of this later.

Then I will have a holy motherfucking shit fit angry rant at the people who deem the ward nurses thick and lazy for not having up to date info on all the patients on their ward at all times.

If there are any nurses (especially outside of Britain) who are reading this I would like to know how many patients you get report on at the beginning of a shift. What would you think of sitting and listening to handover on 35 patients at the beginning of a day shift in acute med-surg? Maybe you'll decide for the only 2 staff nurses on duty to listen to report for both sides and work together. Do you think it would work? If you split it and each took 17 or 18 patients each how would you keep track of your 18 patients and your colleagues 17 patients as well? How can you keep track of all the minute details of 36 people with rapidly changing conditions and orders?

Please answer if you have time. British blog land is full of doctors and members of the public having a shit fit and calling the ward nurses stupid and lazy for not having up to date info or assessments of all 35 patients on a ward at all times.

10 comments:

Hi Anne, As a nurse of the 80's who left the ward situation in 1987 because you could never finish a task for one patient without having to do 25 other things at the same time, I can barely believe the extent to which things have become so dire! (sorry about the long sentence).

Why do we think it is ok to treat nurses in this way? Why do we think that nurses should take the flack from patients and relatives for all of this while managers take cover?

We are generally obsessed with copying US practices - LEO leadership, community matrons etc. But don't think copying staffing ratios and practices would be a good idea.

When I was working as an NA we would have one nurse and 6NAs for 30 patients during the day and 1 Nurse and 2 NAs for night shift on a long term geriatric ward- Deeply dangerous. Why is it acceptable to treat elderly people so badly- this would never be allowed on a surgical unit.

In an atmosphere if universal deceit telling the truth is a revolutionary act. George Orwell.

Why has Nursing Care Deteriorated

Good nurses are failing every day to provide their patients with a decent standard of care. You want to know what has happened? Read this book and understand that similiar things have happened in the UK. Similiar causes, similiar consequences. And remember this. The failings in care have nothing to do with educated nurses or nurses who don't care. We need more well educated nurses on the wards rather than intentional short staffing by management.

About Me

I am a university educated registered nurse. We had a hell of a lot of hands on practice as well as our academic courses. The only people who say that you don't need a brain or an education to be an RN are the people who do not have any direct experience of nursing in acute care on today's wards. I have yet to meet a nurse who thinks that she is above providing basic care. I work with nurses who are completely unable to provide basic care due to ward conditions.
I have lived and worked in 3 countries and have seen more similarities than differences. I have been a qualified nurse for nearly 15 years. I never used to use foul language until working on the wards got to me. It's a mess everywhere, not just the NHS.
Hospital management is slashing the numbers of staff on the ward whilst filling us up with more patients than we can handle... patients who are increasingly frail. After an 8-14 hour shift without stopping once we have still barely scratched the surface of being able to do what we need to do for our patients.

Quotes of Interest. Education of Nurses.

Hospitals with higher proportions of baccalaureate-prepared nurses tended to have lower 30-day mortality rates. Our findings indicated that a 10% increase in the proportion of baccalaureate prepared nurses was associated with 9 fewer deaths for every 1,000 discharged patients."...Journal of advanced nursing 2007

THIS MEANS WE NEED WELL EDUCATED NURSES AT THE BEDSIDE NOT IN ADVANCED ROLES

Dr. Linda Aiken and her colleagues at the University of Pennsylvania identified a clear link between higher levels of nursing education and better patient outcomes. This extensive study found that surgical patients have a "substantial survival advantage" if treated in hospitals with higher proportions of nurses educated at the baccalaureate or higher degree level.

THIS MEANS WE NEED WELL EDUCATED NURSES AT THE BEDSIDE NOT IN ADVANCED ROLES

Dr. Linda Aiken and her colleagues at the University of Pennsylvania's Center for Health Outcomes and Policy Research found that patients experienced significantly lower mortality and failure to rescue rates in hospitals where more highly educated nurses are providing direct patient care.

Evidence shows that nursing education level is a factor in patient safety and quality of care. As cited in the report When Care Becomes a Burden released by the Milbank Memorial Fund in 2001, two separate studies conducted in 1996 - one by the state of New York and one by the state of Texas - clearly show that significantly higher levels of medication errors and procedural violations are committed by nurses prepared at the associate degree and diploma levels as compared with the baccalaureate level.

Registered Nurse Staffing Ratios

International Council of Nurses Fact Sheet:

In a given unit the optimal workload for a registered nurse was four patients. Increasing the workload to 6 resulted in patients being 14% more likely to die within 30 days of admission.

A workload of 8 patients versus 4 was associated with a 31% increase in mortality. (In the NHS RN's each have anywhere from 10-35 patients per RN. It doesn't need to be this way..Anne)

Registered Nurses in NHS hospitals usually have between 10 and 30+ patients each on general wards.

Earlier in the year, the New England Journal of Medicine published results from another study of similar genre reported by a different group of nurse researchers. In that paper, Needleman et al3 examined whether different levels of nurse staffing are related to a patient’s risk of developing complications or of dying. Data from more than 5 million medical patient discharges and more than 1.1 million surgical patient discharges from 799 hospitals in 11 different states revealed that patients receiving more care from RNs (compared to licensed practical nurses and nurses’ aides) and those receiving the most hours of care per day from RNs experienced fewer complications and lower mortality rates than those who received more of their care from licensed practical nurses and/or aides. Specifically for medical patients, those who received more hours per day of care from an RN and/or those who had a greater proportions of their care provided by RNs experienced statistically significant shorter length of stay and lower complication rates (urinary tract infections, gastrointestinal bleeding, pneumonia, cardiac arrest, or shock), as well as fewer deaths from these and other (sepsis, deep vein thrombosis) complications

•Lower levels of hospital registered nurse staffing are associated with more adverse outcomes such as Pneumonia, pressure sores and death.
•Patients have higher acuity, yet the skill levels of the nursing staff have declined as hospitals replace RN's with untrained carers.
•Higher acuity patients and the added responsibilities that come with them increase the registered nurse workload.
•Avoidable adverse outcomes such as pneumonia can raise treatment costs by up to $28,000.
•Hiring more RNs does not decrease profits. (Hospital bosses don't understand this. They think that they will save money by shedding real nurses in favour of carers and assistants. The damage done to the patients as a result of this costs more moneyi.e expensive deaths, complications,and lawsuits, and complaints....Anne)

Disclaimer

I know I swear too much. I am truly very sorry if you are offended. Please do not visit my blog if foul language upsets you. I want to help people. That is why I started this blog and that is why I became a Nurse. I won't run away from Nursing just yet. I want to stick around and make things better. I don't want the nurses caring for me when I am sick working in the same conditions that I am. Of course this is all just a figmant of my imagination anyway and I am not even in this reality. Or am I?Any opinions expressed in my posts are mine and mine alone and do not represent the viewpoint of the NHS, the RCN, God, or anyone else.